Enrollment Agreement / Patient Pays the Fees

Enrollment Agreement / Patient Pays the Fees
Thank you for your interest in enrolling with Finance Your Care. Please complete the information below so we can get your Practice set up, and we can identify the lenders in our portfolio that will be the best fit for your Practice. If you have any questions or concerns, please call (844) 995-4657.
Enrollment Option: Patient Pays

You have chosen to enroll in our program whereby the Patient/Applicant will be responsible for paying all the fees associated with using the Finance Your Care platform. The fees are as follows: Loan amounts up to $2000; the fee is $175. For loan amounts between $2000.01 and $10,000, the fee will be $395. All loan amounts of $10,000.01 and/or above, the fee will be $595. When quoting your price, you will need to add this fee to that amount if the patient/applicant wants to finance it. When you do, the fee will be paid to your Practice when the lender sends you the funds for the transaction. Three days after you are funded, we will automatically invoice your Practice to collect our fee back and charge the credit or debit card you have placed on file. NOTE: If you prefer to enroll in our subscription program, close this form and click on the option for a subscription on the previous page.
Practice Information:
What is the legal name of your Practice*
Make sure you include (LLC, PA, Inc)
What is your Practice specialty (i.e. Chiropractic, Plastic Surgery, etc.)*
What is the Doctor's name

First NameLast Name
What is the Owner's name (if different)

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Practice Phone Number*
What is the Practice email*
Who is the contact person we should call or email?*

First NameLast Name
Contact person's phone number if different than above
Please enter a valid phone number.
Contact person's email if different than above
example@example.com
What is your Practice website?*
About Your Practice and Current Financing Options

The next section ask about your gross sales, current lending options, and average loan volume. This is asked so we can match your current offers with the lenders in our portfolio that should help your approval successes.
What is your Practice Gross Annual Sales*
How many loans do you close every month?*
What is your average loan amount?*
Please list the Patient Financing companies you are currently enrolled with. If you are not offering Patient Financing at this time, just enter "None".*
About the service we provide:

Finance Your Care is a "Fin Tech" company. We DO NOT offer loans or have anything to do with the offers that may be made by a lender. The service we provide to your Practice is a technology platform that provides you with the ability to pre-qualify the Applicant with multiple lenders simultaneously and then enter an application with the lender of your choice.
Final Steps:

After you submit this form, we will complete your onboarding with Finance Your Care, and assign your Practice with a Provider ID. After doing so, we will send you back an email with your Provider ID and schedule a call with you to discuss the lender options. Once we know which of our lenders (and yours) you want to work with, we will complete your lender onboarding and get your platform completed. If you have any questions, please call (844) 995-4657. Thank you!
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Enrollment Agreement / Patient Pays the Fees

Enrollment Option: Patient Pays

Practice Information:

About Your Practice and Current Financing Options

About the service we provide:

Final Steps: